Provider First Line Business Practice Location Address: 
1185 W COUNTY LINE RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GREENWOOD
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
46142-5156
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
317-884-0995
    Provider Business Practice Location Address Fax Number: 
317-882-7882
    Provider Enumeration Date: 
10/04/2011